Bill H.1045
188th (2013 - 2014)

An Act relative to eliminating fraud in the Mass Health medical assistance program

Bill Title: An Act relative to eliminating fraud in the Mass Health medical assistance program

By Representatives O'Connell of Taunton and Holmes of Boston, a petition (accompanied by bill, House, No. 1045) of Robert L. Hedlund and others relative to eliminating fraud in the Mass Health medical assistance program. Health Care Financing.

SECTION 1. (a) For the purposes of this act, the following terms shall have the following meaning:

“division,” the division of medical assistance, established under section 2 of chapter 118E of the General Laws.

(b) The division shall establish a computerized income, asset, and identity eligibility verification system in order to verify eligibility, eliminate the duplication of assistance, and deter fraud within assistance programs administered by the division.

(1) The division may enter into a contract with a third-party vendor for the purposes of developing a system by which to verify the income, asset, and identity eligibility of applicants to prevent fraud, misrepresentation, and inadequate documentation when determining an applicant’s eligibility for assistance prior to the distribution of benefits and during eligibility redeterminations and reviews, as prescribed in this section. The division may also contract with a vendor to provide information to facilitate reviews of recipient eligibility conducted by the division.

(2) If the division enters into a contract with a third-party vendor for the purposes of carrying out this section, the vendor shall be required by contract to establish annualized savings realized from implementation of the verification system and savings shall exceed the total yearly cost to the state for implementing the verification system.

(c) Prior to awarding or continuing assistance, the division shall, to the extent such data bases are available to the division, match the social security number of each applicant and recipient of assistance from the division against the following:

(1) unearned income information maintained by the Internal Revenue Service;

(2) employer quarterly reports of income and unemployment insurance payment information maintained by the Department of Labor and Workforce Development;

(3) earned income information maintained by the Social Security Administration;

(4) immigration status information maintained by the U.S. Citizenship and Immigration Services;

(5) death register information maintained by the Social Security Administration;

(6) prisoner information maintained by the Social Security Administration;

(7) public housing and Section 8 Housing Assistance payment information maintained by the Department of Housing and Urban Development;

(8) national fleeing felon information maintained by the Federal Bureau of Investigation;

(9) wage reporting and similar information maintained by states contiguous to this State;

(10) beneficiary records and earnings information maintained by the Social Security Administration in its Beneficiary and Earnings Data Exchange (BENDEX) database;

(11) earnings and pension information maintained by the Social Security Administration in its Beneficiary Earnings Exchange Record System (BEERS) database;

(12) employment information maintained by the Department of Labor and Workforce Development;

(13) employment information maintained by the U.S. Department of Health and Human Services in its National Directory of New Hires database;

(14) supplemental Security Income information maintained by the Social Security Administration in its SSI State Data Exchange (SDX) database;

(15) veterans’ benefits information maintained by the U.S. Department of Health and Human Services, in coordination with the Massachusetts Department of Health and Human Services and Department of Veterans’ Affairs, in the federal Public Assistance Reporting Information System (PARIS) database;

(16) child care services information maintained by the Department of Children and Families;

(17) utility payments information maintained by the Department of Housing and Community Development under the Low Income Home Energy Assistance Program;

(18) emergency utility payment information maintained by local cities and towns or councils on aging;

(19) a database which is substantially similar to or a successor of a database established in this section; and

(20) a database of all persons who currently hold a license, permit, or certificate from a State agency the cost of which exceeds $1,000.

(d) Prior to awarding or continuing assistance, the division shall match the social security number of each applicant and recipient of assistance from the division against, at minimum, the following public records:

(2) a nationwide public records data source of incarcerated individuals;

(3) a nationwide best-address and driver's license data source to verify individuals are residents of the State;

(4) a comprehensive public records database that identifies potential Identity Fraud or Identity Theft that can closely associate name, social security number, date of birth, phone and address information;

(5) national and local financial institutions, in order to locate undisclosed depository accounts or verify account balances of disclosed accounts;

(6) outstanding default or arrest warrant information maintained by the criminal history systems board, the criminal justice information system, and the warrant management system; and

(7) a database which is substantially similar to or a successor of a database established in this section.

(e) If a discrepancy results between an applicant or recipient’s social security number and one or more of the databases or information tools listed under paragraph (c) and (d), the division shall review the applicant or recipient’s case using the following procedures:

(1) if the information discovered does not result in the division finding the applicant or recipient ineligible for assistance under this section, the division shall take no further action;

(2) if the information discovered under paragraph (c) and (d) results in the division finding the applicant or recipient ineligible for assistance under this section, the applicant or recipient shall be given an opportunity to explain the discrepancy; provided, however, that self-declarations by applicants or recipients shall not be accepted as verification of categorical and financial eligibility during eligibility evaluations and reevaluations. The division shall provide written notice to said applicant or recipient, which shall describe in sufficient detail the circumstances of the discrepancy, the manner in which the applicant or recipient may respond, and the consequences of failing to take action. The applicant or recipient shall have 10 business days to respond in an attempt to resolve the discrepancy. The explanation provided by the recipient or applicant shall be given in writing. After receiving the explanation, the division, whichever applies, may request additional documentation if it determines that there is a substantial risk of fraud;

(3) If the applicant or recipient does not respond to the notice, the division shall deny assistance for failure to cooperate, in which case the division shall provide notice of intent to discontinue assistance. Eligibility for assistance shall not be reestablished until the significant discrepancy has been resolved.

(4) If an applicant or recipient responds to the notice and disagrees with the findings of the match between his or her social security number and one or more databases or information tools listed under this section, the division shall reinvestigate the matter. If the division finds that there has been an error, the division shall take immediate action to correct it and no further action shall be taken. If, after an investigation, the division determines that there is no error, the division shall determine the effect on the applicant or recipient’s case and take appropriate action. Written notice of the division’s action shall be given to the applicant or recipient.

(5) If the applicant or recipient agrees with the findings of the match between the applicant’s or recipient’s social security number and one or more databases or information tools listed under this chapter, the division shall determine the effect on the applicant or recipient’s case and take appropriate action. Written notice of the division’s action shall be given to the applicant or recipient. In no case shall the division discontinue assistance as a result of a match between the applicant’s or recipient’s social security number and one more databases or information tools listed under this chapter until the applicant or recipient has been given notice of the discrepancy and the opportunity to respond.

(f) The division shall promulgate all rules and regulations necessary for the purposes of carrying out this act.

SECTION 2. Nothing in this act shall preclude the division from continuing to conduct additional eligibility verification processes, not detailed in this act, that are currently in practice.

SECTION 3. Section 1 and 2 shall be effective 6 months following the passage of this act.

SECTION 4. Six months following the implementation of section 1 and 2, and annually thereafter, the division shall file with the clerks of the house and senate, a report detailing the effectiveness and general findings of the computerized income, asset, and identity eligibility verification system, as well as which databases or information tools listed under paragraph (c) and (d) were accessed by the system during eligibility determinations and redeterminations.

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